Table Of ContentI
Contents
MEDICAL RADIOLOGY
Diagnostic Imaging
Editors:
A. L. Baert, Leuven
M. Knauth, Göttingen
K. Sartor, Heidelberg
III
Contents
J. A. Verschakelen · W. De Wever
Computed
Tomography
of the Lung
A Pattern Approach
Foreword by
A. L. Baert
With 157 Figures in 356 Separate Illustrations, 43 in Color and 32 Tables
123
IV
Contents
J. A. Verschakelen,
MD, Professor
W. De Wever,
MD
Department of Radiology
University Hospitals Leuven
Herestraat, 49
3000 Leuven
Belgium
Medical Radiology · Diagnostic Imaging and Radiation Oncology
Series Editors: A. L. Baert · L. W. Brady · H.-P. Heilmann · M. Knauth · M. Molls · K. Sartor
Continuation of Handbuch der medizinischen Radiologie
Encyclopedia of Medical Radiology
Library of Congress Control Number: 2006929546
ISBN 10 3-540-26187-7 Springer Berlin Heidelberg New York
ISBN 13 978-3-540-26187-2 Springer Berlin Heidelberg New York
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V
Contents
Foreword
Most radiologists are involved on a daily basis in the performance and interpretation of
CT studies of the lung, one of the most frequent radiological examinations in routine
practice.
The currently available state-of-the-art MDCT technology enables us to study and
display lung anatomy and gross pathology up to the level of the secondary pulmonary
nodule in an exquisite way.
Prof. J.A. Verschakelen and Dr. W. De Wever have taken an original but highly didactic
approach to explaining and teaching the CT features of lung diseases and other diseases
with a pulmonary component.
The numerous superb colour drawings, together with the well chosen high resolution
CT images, enable the reader to better understand the CT changes in patients with pul-
monary diseases, to recognise characteristic appearances and distribution patterns of
the lung parenchyma, and fi nally how to use these patterns to make a correct diagnosis
or to narrow down the number of differential diagnostic possibilities. The fact that all
chapters of this book have been authored by the two editors only ensures that the spe-
cifi c concept and approach of this book is well respected throughout the whole volume.
I congratulate the authors, both internationally well known chest radiologists, for
writing this excellent and remarkable work. I can strongly recommend it to all trainees
in radiology and pneumology, as it provides a perfect guide through the fi eld of HRCT of
the lung, as well as to certifi ed medical specialists who want to update their knowledge
in CT of the lung.
I am confi dent that this volume will meet with the same success among readers as
many of the previous volumes published in this series.
Leuven Albert L. Baert
VII
Contents
Preface
Computed tomography is generally considered to be the best imaging modality for the
assessment of the lung parenchyma. High resolution computed tomography (HRCT)
is able to provide very high morphological detail of the normal and abnormal lung
parenchyma and has been widely accepted as the imaging gold standard for the lung
parenchyma. Many reports have confi rmed the high diagnostic value of this technique,
especially in the study of widespread diffuse or generalized lung disease, which is due to
the HRCT protocol obtaining images at 10- or 20-mm intervals. Spiral CT, and especially
multidetector-row spiral CT, has brought about enormous change in the fi eld of cross-
sectional imaging and also has signifi cant potential for the study of the lung paren-
chyma. This procedure is indeed able to generate volumetric high-resolution CT which
provides a contiguous, detailed visualisation of the lung parenchyma. This visualisation
is no longer limited to the axial plane since multiplanar reformations and three-dimen-
sional volume reconstructions can easily be performed. In addition, high detail imaging
of the lung parenchyma is no longer reserved for the less frequently occurring diffuse
and interstitial lung diseases, but has now become available for the study of all lung
diseases.
Optimal use and interpretation of CT requires good knowledge and understanding of
how the normal lung parenchyma looks on CT, why and how this lung parenchyma may
be affected by disease and how these changes are visualised on a CT image. Furthermore,
in order to have a fruitful discussion with the clinician taking care of the patient and,
when appropriate, with the pathologist, it is important that the radiologist knows and
understands why abnormalities appear as they do.
Giving the readers a clear understanding of why abnormalities appear as they do is
indeed one of the main goals of this book, since this skill will enable them to choose an
appropriate differential diagnosis or even suggest a defi nitive diagnosis, once the CT
fi ndings have been correlated with the clinical situation.
We have opted for a concise and didactic approach by reducing the vast amount of
information available on this topic to what we think is basic and essential knowledge
that allows to recognise and understand the CT signs of lung diseases and of diseases
with pulmonary involvement. We have used the pattern approach because it is well
established and it is considered a good method to accomplish the main goal of the book.
Our approach also has a practical orientation. For this reason, a large section of the book
is dedicated to the description of typical and less typical cases. Analyzing these cases
will help the reader to exercise pattern recognition and to understand why the diseases
present as they do.
VIII
Preface
Furthermore, we have decided to reduce the number of authors to ensure that
the specifi c concept and approach of this book is well respected throughout the
whole volume. However, we want to emphasize that this book could certainly
not have been written without the many informative discussions we had on this
topic with radiologists and pulmonologists, both trainees and certifi ed special-
ists. We want to express our sincere gratitude to each of them. We would espe-
cially like to thank Dr Wim Volders for his valuable suggestions. We also thank
Professor Albert L. Baert, who gave us the unique opportunity to write this book
and to bring it to a successful conclusion.
We hope the reader will enjoy this work and will fi nd it helpful when explor-
ing the perhaps diffi cult but very exciting CT features of lung diseases and dis-
eases with a pulmonary component.
Leuven Johny A. Verschakelen and Walter De Wever
IX
Contents
Contents
1 Introduction
Johny A. Verschakelen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 Basic Anatomy and CT of the Normal Lung
Johny A. Verschakelen and Walter De Wever. . . . . . . . . . . . . . . . . 3
3 How to Approach a CT of the Lung?
Johny A. Verschakelen and Walter De Wever. . . . . . . . . . . . . . . . . 17
4 Increased Lung Attenuation
Johny A. Verschakelen and Walter De Wever. . . . . . . . . . . . . . . . . 29
5 Decreased Lung Attenuation
Johny A. Verschakelen and Walter De Wever. . . . . . . . . . . . . . . . . 47
6 Nodular Pattern
Johny A. Verschakelen and Walter De Wever. . . . . . . . . . . . . . . . . 69
7 Linear Pattern
Johny A. Verschakelen and Walter De Wever. . . . . . . . . . . . . . . . . 87
8 Case Study
Walter De Wever and Johny A. Verschakelen. . . . . . . . . . . . . . . . . 105
Subject Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
1
Introduction
1
Introduction
Johny A. Verschakelen
The use of computed tomography in the study of the secondary pulmonary lobule, often be identifi ed
lung diseases is well established. Many reports have and differentiated from each other. This explains
indeed emphasised its role not only in the detec- why the diagnosis of lung disease with CT is to a
tion and diagnosis but also in the quantifi cation and large extent based on the study of the distribution
follow-up of both focal and diffuse lung diseases. of the disease.
Moreover, CT has helped to better understand the Another important element to diagnosing lung
clinical and pathological course of some diseases disease with CT is the study of the disease ap-
while some CT classifi cations are used now to cat- pearance pattern. Recognition of the appearance
egorise disease. pattern often allows developing an appropriate
CT interpretation, however, remains diffi cult. differential diagnosis list including all the major
CT fi ndings are often not specifi c and can change categories of disease that might lead to the iden-
during the course of the disease. In addition, the CT tifi ed pattern. Although the recognition of a pat-
changes often have more than one pathological cor- tern may be easy and straightforward, some lung
relate, abnormalities can occur before clinical symp- changes are diffi cult to categorise because patterns
toms develop and clinical symptoms may be present are very often mixed or change during the course
before CT abnormalities become evident. That is of the disease. Nevertheless, in order to make a di-
why a fi nal diagnosis, especially in a patient with agnosis or an adequate differential diagnosis list,
diffuse interstitial lung disease, is often only pos- the exercise of trying to categorise the CT changes
sible when clinicians, pathologists and radiologists into one or more specifi c patterns should always be
work closely together. To make such cooperation done. This is certainly true when diffuse lung dis-
successful, it is very important that the pathological ease is studied, but is often also very helpful when
correlate of the CT changes is very well understood. focal lung disease or diseases involving only a few
In fact, when looking at the CT features, at least at a lung areas are encountered.
submacroscopic level, one should be able to predict The subtitle of this book is “A pattern approach”.
the pathological changes, but also vice versa: when Indeed an important objective of this book is to
reading the report of the pathologist, one should be help the reader to identify the disease pattern: i.e.
able more or less to imagine how the CT scan could the appearance and distribution pattern of the dis-
look. Today’s CT techniques can offer such good im- ease. Tools and illustrations are provided that not
age quality that these correlations between CT and only help to recognise these patterns but that also
pathology become easier. Not only the improved help to understand why disease can present with a
detail of high resolution computed tomography, but particular pattern. The book is organised accord-
also the ability to produce highly detailed reformat- ing to the different appearance patterns that can be
ted images is responsible for this. encountered on a CT scan of the lungs. After an in-
CT is now able to study the lung anatomy and troductory chapter on how a CT of the lung should
pathology at the level of the secondary pulmonary be approached, several chapters describe the differ-
lobule, which is a unit of lung of about 0.5–3 cm. CT ent patterns in detail: (1) increased lung attenua-
can discover different components of this secondary tion, (2) decreased lung attenuation, (3) the nodular
pulmonary lobule, especially when they are abnor- pattern and (4) the linear pattern. Once the appear-
mal. This is particularly helpful in the study of the ance pattern(s) is/are determined, the distribution
distribution pattern of the disease since the airway, pattern should be identifi ed. In each chapter, a great
vascular, lymphatic and intestitial pathways of dis- deal of attention is therefore provided on how com-
tribution can, because of their specifi c relation to bining disease pattern and distribution pattern can
2
J. A. Verschakelen
lead to a diagnosis or a narrow differential diagnosis
list. Diagrams are provided for this purpose. A good (cid:2) Basic objectives of the book
understanding of the disease and distribution pat-
tern is only possible when the anatomy of the lung (cid:2) Learn to detect and understand the CT changes
is well known. That is why a chapter on basic ana- in patients with lung disease
tomical considerations is included and precedes the
(cid:2) Learn to recognise and to determine the dif-
chapters dealing with the different patterns. Finally,
ferent appearance and distribution patterns of
the CT features of the most frequently occurring
lung disease
focal and especially diffuse lung diseases will be
(cid:2) Learn to use these patterns to make a diagnosis
shown and their appearance and distribution pat-
or to narrow the differential diagnosis list
terns will be listed.
